What is the initial management of acute cholangitis and cholecystitis according to the Tokyo guidelines?

Initial Management of Acute Cholangitis and Cholecystitis

For acute cholangitis, immediately administer broad-spectrum antibiotics within 1 hour if septic shock is present (or within 4 hours if stable), assess severity using the three-tier Tokyo Guidelines grading system, and perform urgent biliary drainage for Grade III (severe) disease or early drainage for Grade II (moderate) disease if initial medical treatment fails within 12-24 hours. 1, 2, 3

Immediate Assessment and Stabilization

Vital Signs and Urgency Determination

• Measure vital signs immediately upon presentation to determine if the situation is urgent, and begin initial medical treatment including respiratory/circulatory management without waiting for definitive diagnosis if the case appears critical 3
• Look specifically for signs of organ dysfunction: cardiovascular instability (hypotension requiring vasopressors), respiratory dysfunction (requiring ventilatory support), neurological dysfunction, renal dysfunction, hepatic dysfunction, or hematological dysfunction 1, 4

Antibiotic Administration Timing

• Administer antibiotics within 1 hour in cases of septic shock 1, 2
• Administer antibiotics within 4 hours after diagnostic studies in cases without shock 1, 2
• Use broad-spectrum empiric coverage including piperacillin/tazobactam, carbapenems (imipenem/cilastatin, meropenem, ertapenem), or 4th-generation cephalosporins targeting Gram-negative enteric bacteria 5, 1, 2

Diagnostic Workup

Clinical Diagnosis

• Diagnose acute cholangitis when Charcot's triad is present: fever/chills, right upper quadrant or epigastric abdominal pain, and jaundice 4
• When the complete triad is absent, confirm diagnosis with laboratory data showing inflammation (elevated WBC or CRP) plus imaging demonstrating biliary obstruction or dilatation 1, 4

Imaging Strategy

• Perform trans-abdominal ultrasound as first-line imaging for initial evaluation, which detects cholelithiasis in approximately 98% of cases 1
• Use advanced imaging (MRCP or EUS) for common bile duct stone detection when ultrasound is inconclusive 1, 2
• Reserve CT imaging for unstable patients, high suspicion of malignancy, or suspected hepatic abscesses 1

Acute Cholecystitis Diagnosis

• Require local signs of inflammation (Murphy's sign) and systemic signs (fever) for definite diagnosis 1
• Ultrasound showing stones plus ultrasonographic Murphy's sign has a 92% positive predictive value 1

Severity Assessment Using Tokyo Guidelines Classification

Grade III (Severe) - Presence of Organ Dysfunction

• At least one new-onset organ dysfunction defines severe cholangitis: cardiovascular, respiratory, neurological, renal, hepatic, or hematological 1, 4
• Requires urgent biliary drainage within hours after hemodynamic stabilization 1, 6, 3
• Provide appropriate organ support and intensive care management 6, 3

Grade II (Moderate) - Non-Responsive to Initial Treatment

• Defined by any two prognostic factors: abnormal WBC count, high fever (≥39°C), age ≥75 years, hyperbilirubinemia (total bilirubin ≥5 mg/dL), or hypoalbuminemia (<0.7× lower limit of normal) 1
• Perform early biliary drainage if no response to initial medical treatment within 12-24 hours 1, 6, 3
• Endoscopic drainage is preferred over surgical approach 1

Grade I (Mild) - Responsive to Initial Treatment

• Clinical findings and laboratory data improve with initial medical treatment 4
• Initial medical treatment including antibiotics is sufficient for most cases 6, 3
• Consider biliary drainage only if patient does not respond to initial treatment 6, 3

Biliary Drainage Strategy

Drainage Timing by Severity

• Grade III (Severe): Urgent drainage within hours after hemodynamic stabilization 1, 3
• Grade II (Moderate): Early drainage, especially if no improvement within 12-24 hours of medical treatment 1, 6
• Grade I (Mild): Drainage only if non-responsive to medical management 6, 3

Drainage Method Selection

• Endoscopic drainage is the preferred first-line approach for all severity grades 1
• Percutaneous transhepatic drainage or EUS-guided drainage are alternative methods when endoscopic approach is not feasible 2, 3
• Avoid surgical drainage in severe cholangitis due to high morbidity and mortality 2

Combined Procedures

• For Grade I cholangitis with choledocholithiasis, endoscopic sphincterotomy and stone extraction may be performed simultaneously with biliary drainage if the patient's condition permits 6, 3
• For Grade II and III, treat the underlying etiology only after the patient's general condition has improved 6, 3

Antibiotic Duration and Adjustment

Duration Based on Drainage Success

• Limit antibiotic therapy to 3 days post-drainage in cases with successful biliary drainage 1, 2
• Continue antibiotics until anatomical resolution in cases with incomplete drainage or residual stones 1
• Treatment should last no more than 24 hours for prophylaxis in uncomplicated cases 5

Antibiotic Adjustment

• Adjust therapy according to bile and blood culture results when available 5, 2
• In cases of biliary fistula, biloma, or bile peritonitis, use piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem, or aztreonam associated with amikacin in cases of shock 5
• Add fluconazole in fragile patients and cases of delayed diagnosis 5

Management of Acute Cholecystitis

Grade I (Mild) Cholecystitis

• Early laparoscopic cholecystectomy is the first-line treatment 6
• Perform surgery during the same admission when feasible 6

Grade II (Moderate) Cholecystitis

• Initial medical treatment with antimicrobial agents followed by delayed/elective laparoscopic cholecystectomy is the first-line approach 6
• Consider gallbladder drainage in non-responders to initial medical treatment 6

Grade III (Severe) Cholecystitis

• Provide appropriate organ support in addition to initial medical treatment 6
• Perform urgent or early gallbladder drainage 6
• Elective cholecystectomy can be performed after improvement of the acute inflammatory process 6

Critical Pitfalls to Avoid

• Do not delay antibiotic administration beyond 1 hour in septic shock or 4 hours in stable patients 1, 2
• Do not attempt surgical drainage as first-line therapy in severe cholangitis due to excessive mortality risk 2
• Do not continue antibiotics beyond 3 days if successful biliary drainage has been achieved, as this promotes resistance without added benefit 1, 2
• Do not perform definitive treatment of underlying etiology (such as stone extraction) in Grade II or III cholangitis until the patient's condition has stabilized 6, 3